Cycle 1
Health 2024-11-26 · Fire 2024-11-26
4 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lyons, NY
Wayne County Nursing Home
1-star overall rating with 1-star inspections with $24,850 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1529 Nye Road, Lyons, NY
(315) 946-5673
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
192
Certified beds
Average residents
132
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.75
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9925
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.85
Baseline 21.23% · Performance 19.65% · Measure score 3.85 · Achievement 3.85 · Improvement 3.26
Healthcare-associated infections
1.63
Baseline 7.21% · Performance 7.35% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Total nurse turnover
7.30
Baseline 35.95% · Performance 33.84% · Measure score 7.30 · Achievement 7.30 · Improvement 1.40
Adjusted total nurse staffing
3.04
Baseline 4.16 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 9.33% · Lower 95% interval 7.22% |
| Discharge to community | 48.36% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 42.11% · Lower 95% interval 36.58% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.48% |
95.27%
1.8 pts worse
|
Numerator 43 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 37.14% |
53.69%
16.5 pts worse
|
Numerator 13 · Denominator 35 |
| Discharge mobility score | 45.71% |
50.94%
5.2 pts worse
|
Numerator 16 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 2 · Denominator 46 · Adjusted rate 3.96% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 7.1% |
8.2%
1.1 pts worse
|
Numerator 12 · Denominator 169 |
| Staff flu vaccination coverage | 72.11% |
42%
30.1 pts better
|
Numerator 137 · Denominator 190 |
| Discharge function score | 45.71% |
56.45%
10.7 pts worse
|
Numerator 16 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 39.13% |
25.2%
13.9 pts better
|
Numerator 9 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.2%
7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 97.0% · Q3 97.7% · Q4 99.2% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.0%
1.5 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.8% · Q3 6.1% · Q4 5.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
18.5%
17.2 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.5% · Q3 0.8% · Q4 0.9% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.1%
0.4 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.3% · Q3 8.3% · Q4 2.7% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
13.5%
7.6 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 20.2% · Q3 23.1% · Q4 23.9% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
14.8%
7.4 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.2% · Q3 7.8% · Q4 14.6% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.7% |
15.1%
11.6 pts worse
|
16.3%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 32.8% · Q3 31.0% · Q4 16.7% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.2% |
15.5%
17.7 pts worse
|
14.9%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 33.3% · Q3 40.0% · Q4 27.2% · 4Q avg 33.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.4%
1.3 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 4.6% · Q4 4.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
20.8%
12.1 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.3% · Q2 34.5% · Q3 30.5% · Q4 30.4% · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
6.9%
2.3 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 10.4% · Q3 11.9% · Q4 6.9% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
76.7%
18.5 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.0% · Q2 97.9% · Q3 97.5% · Q4 92.0% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
9.7%
6 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 14.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
78.8%
12.7 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
20.6%
2.4 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 14.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-15 · Fire 2020-01-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-11-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-25
F · Potential for more than minimal harm
2022-10-13
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-27
E · Potential for more than minimal harm
2022-10-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-12-27
F · Potential for more than minimal harm
2020-01-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-14
F · Potential for more than minimal harm
2020-01-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-14
C · Minimal harm
2020-01-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-03-14
Inspection history
Recent health citations
L · Immediate jeopardy
2025-11-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-12-24
E · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-11-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-01-25
D · Potential for more than minimal harm
2024-09-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-17
F · Potential for more than minimal harm
2022-10-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-13
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-12
D · Potential for more than minimal harm
2020-01-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-14
D · Potential for more than minimal harm
2020-01-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-03-14
C · Minimal harm
2020-01-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2020-03-14
Penalties and ownership
What sits behind the stars
$24,850
2025-11-07
Fine
Fine · fine $24,850
Fine
Ownership
County Of Wayne
5% Or Greater Direct Ownership Interest · Organization
County Of Wayne
Operational/Managerial Control · Organization
Schabel, Scott
Operational/Managerial Control · Individual
Stalker, Jeffrey
Operational/Managerial Control · Individual
Nearby options
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#2
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3-star overall rating with 3-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Clifton Springs Hospital and Clinic Extended Care
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4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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